Deep Roots for Lack of Minorities in American Medical Schools

Problem starts in 3rd grade

Student groups across the country have been calling attention to the lack of diversity on medical campuses, pushing administrators to recruit and enroll more minority students to help end racial health disparities that have persisted for decades. But creating a more diverse class of doctors-to-be isn't so simple.

Despite progress made over the last several decades, there aren't enough minority medical school applicants. And the origins of the problem could start as early as third grade.

"The pipeline itself is just too small," Marc Nivet, EdD, MBA, chief diversity officer of the Association of American Medical Colleges (AAMC), told MedPage Today. "The barriers exist up and down the continuum to our segregated education system ... Too many of our minority students are in poor-performing or underperforming K-12 school systems."

Doctors Who Don't Reflect the General Population

According to the latest data from the U.S. Census Bureau, 62.1% of the U.S. population is white, 17.4% is Hispanic, 13.2% is black, and 5.4% is Asian.

By comparison, 60.1% of students entering med school from the 2013-14 academic year through the 2015-16 academic year have been white, 22% Asian, 9.8% Hispanic, and 7.5% black, according to the latest data from AAMC, which runs the MCAT, the standardized test that aspiring physicians (MDs and DOs) must take to get into med school.

This mismatch between the racial breakdown of the population and that of doctors causes problems, even if the biases aren't explicit, studies have shown again and again. In 2008, the American Medical Association issued an apology for a century of racial discrimination in the organization's past.

White Coats for Black Lives, an offshoot of the Black Lives Matter movement, has attempted to draw attention to racial injustices happening in medicine since its first "die in" protest in late 2014. They've called for an acknowledgment of racism's role in creating health disparities, including the ongoing segregation of healthcare based on insurance status, which they called "colorblind" racial discrimination in an editorial published last fall in the Journal of Urban Health.

A crucial step toward equality in healthcare is raising the number of minority doctors, medical students, and medical professionals in leadership positions, they say.

But fewer black students applied to and enrolled in medical school in 2014 than in 1978, according to AAMC. According to its report entitled Altering the Course: Black Males in Medicine, the problem goes all the way back to grade school math and science courses offered to black students.

Examining the Pipeline

A look at the data suggests the largest proportion of would-be minority physicians are lost long before it's time to apply to medical school.

Of the 1.6 million students who received bachelor's degrees in 2010, 9% were black and 77.5% were white, according to the latest data from the U.S. Department of Education. But according to 2010 census data, black people made up 14.4% of the population of 20- to 24-year-olds, and white people made up 67.3% of the same age group.

The same year, 3,475 black students applied to medical school, making up 8.1% of all medical school applicants, according to data from AAMC; there were 46,410 white applicants, 61.8% of the total applicant population.

Of the 165,000 black students who received bachelor's degrees in 2010, 2.1% of them went on to apply to medical school. By comparison, 2.3% of the 1.2 million white students who received bachelor's degrees that year applied to medical school.

In other words, by the time students receive undergraduate degrees, blacks and whites are on a nearly equal footing. The disparity develops earlier.

In fact, minority students start to fall behind on their standardized test scores as soon as third grade, and the gap widens over time, Nivet said. To make matters worse, 17 states don't require students to pass algebra II to graduate, meaning public school students aren't pushed to take it or the math and science classes that follow.

"We don't have enough minority students taking the right classes early on and becoming successful in those classes early on to make successful applicants to any health professional school," Nivet said.

Damon Tweedy, MD, who published his personal story Black Man in a White Coat last year, told MedPage Today that he credits a special teacher for pushing him to apply to a magnet program before he started high school. He got in, and was bused from the school in his predominantly working class black community to a school in a mostly white neighborhood.

Secondary Barriers to Med School

More could be done to encourage minority undergraduate students to consider medical school, Nivet and Tweedy said.

Secondary barriers continue into students' undergraduate programs, which are often at historically minority-heavy schools, if their college doesn't have a full time-medical school adviser to guide pre-med students, Nivet said.

This can range from telling them not to take organic chemistry and physics the same semester to telling them what's an acceptable MCAT score. Nivest said he occasionally hears about minority students whose advisors discourage them from applying to medical school even when they have average MCAT scores that most medical schools would be happy to accept.

Tweedy said that schools that lack diversity may also be more passive about their recruitment methods.

"Medical school is an incredible burden," said Tweedy, who is also a psychiatry professor at Duke University Medical Center. "That alone, the time it takes and the cost itself, may deter people from otherwise even considering it. That's where someone like a recruiter could talk about various options for financial aid, invite students to at least apply and waive the application fees. All these things make it more accessible."

Lower Med School Acceptance Rates And Test Scores

Racial disparities don't disappear with the application process. From 2013-14 through 2015-16, acceptance rates were lower for black students compared with other racial groups, according to MCAT and GPA data from AAMC, which does not include schools that are part of the American Association of Colleges of Osteopathic Medicine (AACOM).

Although 45.2% of white applicants got accepted into medical school -- as well as 44.3% percent of hispanic applicants and 42.1% of Asian applicants -- only 36.2% of black applicants were accepted.

Part of this may be tied to lower test scores. A look at the data shows that as the scores go up, the proportion of black students earning those scores goes down.

Of the 2,460 students who earned the lowest scores on the MCATs from 2013-14 through 2015-16, 43% were black. Of the 221 top-scoring medical school applicants over the same period, however, only 24 were black.

Fighting The False Narrative

And once they're accepted into medical school, some minority students have a hard time shaking the "false narrative" that they don't deserve to be there, Nivet said.

When Tweedy was a first year medical student at Duke University in the 1990s, his professor mistook him for a handyman, Tweedy wrote in his book. He recalled feeling insecure about whether he was inferior to his classmates at the beginning of medical school once he learned that his MCAT score was "a few points below the class average" and that his classmates had come from Ivy League schools and other prestigious undergraduate institutions. He wrote that he knew his full scholarship to Duke's medical school was the result of affirmative action, but wondered whether he was about to become an "academic casualty."

Rowan University School of Osteopathic Medicine in New Jersey has a series of pipeline programs to recruit a diverse class of medical students early, but some students -- not just minorities -- have test scores or GPAs that indicate they may have trouble later on in their medical education, Thomas Cavalieri, DO, the school's dean, told MedPage Today. As a result, the school has a boot camp-like program that starts before the official school year begins to get these students up to speed. It also has a number of interventions to help struggling students throughout their medical education.

Nivet said it's especially important for minority students to remember that being around or below the class average MCAT score isn't a big deal -- and that they're not the only ones in the bottom half of their class.

"A whole bunch of white kids have lower MCAT scores," he said. "Duke University is not 'taking a chance' on any kid.... Students who go to these elite institutions graduate and have become leaders across this country in medicine."

Why Diversity Matters In the Real World

Medical student Ashley White-Stern was pouring over a gastroenterology textbook one night a few months ago when she came across a passage that made her bristle: "In the United States, H. pylori infection is associated with poverty, household crowding, limited education, African American or Mexican American ethnicity, residence in areas with poor sanitation, and birth outside the United States."

White-Stern, a medical student at Columbia University who is black, told MedPage Today that the passage wasn't overtly racist, but medical students reading it could come away with a subtle bias about blacks and Mexican Americans without realizing it. So she decided to email the authors of the textbook.

"If we didn't live in a country or world where being of color predisposed society to look down on a person, the published sentence [would] not raise an eyebrow," White-Stern wrote in her email to the authors. "My humble belief is that we owe it to people of color to consider how and when we include their identities in lists of 'undesirable' characteristics."

Within 24 hours, the authors called White-Stern, thanked her, and asked her to help them change the passage. The next version will explain each association in a little bit more detail and add that higher rates of infection among black and Mexican Americans are not completely understood.

"Unless you have a diverse class, you can't have that discussion," White-Stern told MedPage Today.

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